H+N: Oral Cavity, Naso, Nasal Cavity, Salivary Glands

Who is most commonly affected by oral cavity cancer?

Common in men over age of 40 or aggressive histology

What are the etiological risk factors for oral cavity cancer?

Tobacco, alcohol, betel nut, areca nut, HPV

What are the anatomical structures of the oral cavity?

Anterior ⅔ of tongue, lips, floor of mouth, hard

palate, alveolar ridge, buccal mucosa.

What are the borders of the oral cavity?

Superior = hard palate; Inferior = floor of mouth; Posterior =

circumvallate papillae; Anterior = lips.

What are the lymphatic drainage sites of the tongue?

Primary level 2 (upper jug), 3 (mid jug), 4 (low jug), 1B (submandib), 1a (subment)

What is the histopathology of oral cavity cancer?

SCC

What are the clinical presentations of oral cavity cancer?

Non-healing ulcer, facial swelling, referred otalgia (referred ear pain)

How is oral cavity cancer diagnosed?

Biopsy or scrape cytology

What is the staging procedure for oral cavity cancer?

CT, MRI, PET-CT, US ± FNA

Main prognostic factors for oral cavity cancer?

Size, location, extent, mandible involvement

What is the radical RT dose for oral cavity cancer?

70/35fx with concurrent cisplatin

When is brachytherapy used for oral cavity cancer and what is the dose used?

Accessible lesions that is <3cm away from bone, no LN involvement, 34-40Gy

Define leukoplakia and erythroplakia. What has mor malignant potential?

Leukoplakia = white patches
Erythoplakia = angry red patches = more potential

What is the geographic epidemiology for NPC?

East/South East Asia

Main etiological factors for NPC

EBV (most common), HPV, salted fish, smoking, work exposure

What are the borders of the nasopharynx?

Superior = sphenoid sinus;
Inferior = soft palate;
Anterior = nasal cavity;
Posterior = clivus/upper C-spine;
Lateral = parapharyngeal space.

Where does the nasopharynx drain lymphatically?

Retropharyngeal and level 2 (upper jug)/anterior cervical

What are the 4 types of WHO NPC classifications?

Keratinizing SCC
Non-keratinizing differentiated (HPV/EBV)
Non-keratinizing undifferentiated (HPV/EBV)
Basaloid SCC

What is another common histology of NPC?

Lymphoepithelioma — more radiosensitive and better prognosis than SCC

What are the presenting symptoms of NPC?

Neck mass, nasal obstruction, epistaxis, tinnitus, cranial nerve palsy

How is NPC diagnosed?

Primary/nodal biopsy, EBER staining (EBV)

What is the CIBC mnemonic for NPC workup?

- C = Clinical exam

- I = Imaging (CT/MRI/PET)

- B = Bloodwork (CBC, liver function, plasma EBV)

- C = Consultations (dental, ophthalmology, dietician)

Most common distant mets sites for NPC?

Bone, lungs, liver

What cranial nerves are involved in NPC spread?

Trigeminal (CN5), Oculomotor (CN3), Trochlear (CN4)

What is the primary tx modality for NPC?

Radiation therapy

What is the standard dose RT dose for NPC?

70/35

When is cisplatin added to NPC treatment?

When there is nodal involvement

When is induction chemo (gemcitabine) used before chemorads?

Advanced stage disease: T4, T3N1, or any T with N2+ disease

What OAR requires a PRV (planned risk volume) when treating NPC?

Optic Chiasm ( <5500 cGy)

What is the epidemiology of nasal/paranasal sinus cancers?

Rare disease, more common in males in their 60s

What are the etiological risk factors for nasal/paranasal cancers

Wood dust, nickel smelting, smoking, EBV, HPV

What are the anatomical structures involved in nasal/paranasal cancers

Frontal, ethmoid, nasal cavity, maxillary, sphenoid sinus

Where does the nasal/paranasal drain lymphatically?

Cervical LN (Level 6)

What are the common histopathologies for nasal/paranasal?

SCC, Adenoid cystic carcinoma, adenocarcinoma (linked with wood dust and ethmoid sinus)

What are the most common presenting symptoms?

Nasal obstruction, epistaxis, anosmia, proptosis (bulging of eyeballs), headache, pain

Most critical OARs for nasal/paranasal treatment?

Optic chiasm, brain, brainstem, spinal cord

Common distant mets for nasal/paranasal?

Lung

What is the treatment modality for nasal/paranasal and its dose?

Surgery and Adjuvant RT 70/35 Gy.

RT can be neoadjuvant for debulking

What is the most common primary site for nasal/paranasal cancer?

Maxillary → Nasal cavity → ethmoid

What histology type is associated with wood dust and the ethmoid sinus?

Adenocarcinoma

What is the epidemiology of salivary gland tumors?

Rare occurrence, benign at age 40 and malignant at age 55. More common in males

What are the etiological risk factors of salivary gland cancer

Previous rads, EBV, smoking, family hx

Most common histology for parotid gland cancer

Mucoepidermoid carcinoma

Most common histology for submandibular gland cancer

Adenoid cystic carcinoma

What are common presentations of salivary gland cancer?

Painless mass, variable growth, pain, adenopathy, facial palsy

What are the diagnostic methods for salivary glands

FNA, core biopsy

Common distant mets for salivary glands?

Lung, liver

Most common RT side effects for salivary glands

Xerostomia, dysphagia

What surgery is done for benign parotid tumors?

Superficial parotidectomy

What surgery is done for advanced malignant parotid tumors?

Total parotidectomy + neck nodal dissection

What is the unresectable RT dose for salivary gland tumors?

70/35fx ± bolus, bite block.

What is the adjuvant RT dose for salivary gland tumors

66/33fx

What are the types of benign salivary gland tumors?

Pleomorphic adenoma, Warthin’s tumor, oncocytomas

What is the functional difference between parotid and submadibular saliva?

parotid = eating saliva
subamdibular = baseline saliva

What classifies as Level 1 LN drainage and what sites primarily drain here?

1A = Submental
1B = Submadibular
Primary sites: Tip of tongue (1A), Oral cavity, Lip, Floor of mouth (1B)

What classifies as Level 2 LN drainage and what sites primarily drain here?

Upper deep cervical (jugulodigastric)
Primary sites: Oral tongue, nasopharynx, oropharynx, larynx

What classifies as Level 3 LN drainage and what sites primarily drain here?

Middle deep cervical
Primary sites: Oral cavity, oropharynx, larynx, hypopharynx

What classifies as Level 4 LN drainage and what sites primarily drain here?

Lower deep cervical
Primary sites: Larynx, hypopharynx, thyroid, oral cavity

What classifies as Level 5 LN drainage and what sites primarily drain here?

Posterior Triangle
Primary sites: nasopharynx, scalp, thyroid

What classifies as Level 6 LN drainage and what sites primarily drain here?

Anterior compartment
Primary sites: Thyroid, subglottic larynx, trachea

What classifies as Level 7 LN drainage and what sites primarily drain here?

Superior medistinal
Primary sites: Thyroid, subglottic, trachea

Why is IMRT advantageous for H&N?

1. Concave dose distributions to spare salivary glands

2. Reduce xerostomia

3. Allow increase dose to tumor while decreasing to OARs

4. 5-fld IMRT spares salivary gland dose

What are RT H+N acute side effects and what dose do they occur?

Dysgeusia = 1000cGy
Xerostomia = 2000cGy
Mucositis = 2000-3000 cGy
Dental caries = 5000-6000 cGy